The Norplant Option

The Norplant Option

A sensible, humane alternative that wasn't even considered during the welfare-reform debate.

Now that Congress and President Clinton have opted to use the threat of utter destitution to dissuade poor teen-agers and women from having children on the public dole, it's time to revive a more humane, and perhaps more effective, proposal with the same objective.

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This idea surfaced briefly and spectacularly in 1990, when the Philadelphia Inquirer suggested in an editorial that perhaps some welfare mothers should be "offered an increased benefit" if they would agree to practice effective birth control--specifically, to use the then-new Norplant contraceptive, which prevents pregnancy for five years after being implanted under the skin of the upper arm.

An uproar followed. The editorial writers--who had insensitively suggested a desire to reduce births of poor black babies in particular--were savaged by many Inquirer staffers and others as racist advocates of eugenics, even of "genocide." They also caught it from some abortion-rights zealots, who are suspicious of any government efforts to influence reproductive choices, and from conservatives, who think the only proper way to discourage teen pregnancy is to preach abstinence. The newspaper abjectly apologized for a "misguided and wrongheaded editorial opinion." And ever since, the whole subject has been taboo.

But it's still a good idea, for poor girls and women themselves, and for the rest of us. Millions of babies are being born to poor teen-agers so lacking in elementary skills, work habits, and self-discipline that they are unlikely to be either responsible parents or self-supporting providers. Many of these babies grow up in squalor and themselves become dependent denizens of the welfare culture.

The only realistic hope for breaking the bleak cycle of teen pregnancy and welfare dependency is to find ways to persuade poor teen-agers not to have babies--at least, not until they are old enough, and capable enough, and self-supporting enough to provide a decent home life. But nobody--nobody--has any great ideas for realizing this hope, short of reverting to the cruelest, let-'em-starve brand of social Darwinism.

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Thoughtful progressives like Sen. Daniel Patrick Moynihan, D-N.Y., have properly stressed the need to push welfare mothers into jobs and job-training programs. This makes sense because some of these women will rise to the occasion, learn the work ethic, and become self-supporting. And others may be dissuaded from having children by the prospect of being required to work. But (as Moynihan acknowledges) many welfare mothers are so crippled by their own early childhood environments as to be essentially unemployable, no matter how well-financed and well-run the jobs programs and related counseling, training, and child-care programs.

And under the harsh new welfare reform, the jobs programs will not be well financed. It appears that millions of welfare mothers and children will simply be cut off--unable to get or hold jobs, and left to beg from relatives and strangers, to steal what they can, even to sleep on the streets, depending on how much Calcutta-style misery the taxpayers are willing to tolerate.

Given the stark ugliness of trying to end the welfare culture by spreading homelessness and hunger, it's especially striking that one pretty good, pretty humane idea has been virtually ignored in the welfare debate of the past year.

In a small effort to reopen discussion of this option, here's a specific proposal: States should experiment with programs in which all qualifying teen-agers and women would be offered lump-sum $1,000 cash payments--on top of any other benefits they receive--to have Norplant (or another long-term contraceptive) implanted at government expense. They would be free to have it removed whenever they chose, but would be rewarded with additional payments (of, say, $30) for each month in which they kept it.

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The category of qualifying teen-agers and women could include all recipients of welfare or other public assistance (including daughters of recipients) who are competent to give informed consent to the implant procedure. Or the program could be restricted in various ways in order to blunt possible objections. For example, you could require parental consent. Or, eligibility could be restricted to those who have already been pregnant, or at least sexually active; to those over age 13, or under age 21; or some combination thereof.

Why Norplant? Because it requires no ongoing effort or supervision to be effective, and it can be discontinued only after some (rather small) effort. As such, Norplant is the only contraceptive the government could pay people to use with any hope of affecting those who aren't strongly motivated to either become pregnant or avoid pregnancy.

How much good the Norplant option would do is debatable. But the arguments that it would do harm seem unpersuasive. Here's a quick review of possible objections, left and right:

Bribing poor women and girls to implant Norplant would coerce them into not having children, thus violating their rights to reproductive choice, like the one-child-per-family policy and coerced abortions in China.

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To the contrary, a government offer of money is not coercion--and not even remotely comparable to what goes on in China. Existing benefits would not be reduced for anyone declining Norplant. This means that nobody who really wanted a child would be prevented from having one. To be sure, the government would be trying to influence reproductive choices. But the same is true of existing policies promoting free contraception, and of laws like the Hyde Amendment, which denies Medicaid funding for abortions--not to mention the still extant statutes making it a crime to commit statutory rape (sex with a consenting minor), fornication (premarital sex), and adultery.

In its groveling 1990 editorial apology, the Inquirer said: "Our critics countered that to dangle cash or some other benefit in front of a desperately poor woman is tantamount to coercion. They're right." No, they were wrong, and the Inquirer was right in its initial Norplant editorial, when it noted that women would be free to "change their minds at any point and become fertile again."

"Many people," David Boldt, then-editor of the Inquirer's editorial page, noted in a subsequent commentary, "saw the editorial as part of an ongoing white conspiracy to carry out genocide of blacks in America."

This is pernicious nonsense, no matter how many people say it. The original Inquirer editorial unwittingly invited such smears by linking its Norplant proposal to race--specifically, to a report that nearly half the nation's black children are living in poverty. But nobody is proposing that race be a factor in any program promoting Norplant to welfare recipients, most of whom are white. Nobody is proposing to sterilize women or forbid them from having children. And while a disproportionate percentage of welfare mothers and children are black, black America, like white America, can only benefit from any program that rewards people for avoiding pregnancy unless and until they are old enough and self-supporting enough to provide decently for children.

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Girls and women on Norplant may be at greater risk of contracting and spreading AIDS, because they will be less likely to demand that their sex partners use condoms.

A 1994 study reported in The New England Journal of Medicine found that Norplant had no effect on recipients' decisions whether to use condoms or visit doctors--and was 19 times as effective as the pill in preventing pregnancy. Any Norplant incentive program should include vigorous counseling about the need to use condoms against disease. But even now, how many women and girls are so much more afraid of pregnancy than of death that they use condoms solely to avoid the former, and would stop once on Norplant? Not many, I suspect.

Norplant itself may be unhealthy.

The possibility of serious long-term health damage from any relatively new contraceptive like Norplant must be taken seriously, and the risks should, of course, be fully disclosed to women considering using it. But no contraceptive is risk-free. And the available evidence indicates that the risks inherent in pregnancy and childbirth--and in abortion--are at least as great as the risks inherent in Norplant.

Plaintiffs' tort lawyers have nearly killed off Norplant, scaring away many women and doctors, by a torrent of personal-injury suits against its manufacturer. The lawyers include many of the same folks who created a tidal wave of litigation based on the apparently bogus claim about the dangers of silicone breast implants. But the Food and Drug Administration has repeatedly found Norplant to be safe and effective. More than a million women have used it with only minor side effects, such as changing menstrual bleeding patterns, reported.

There have been complaints by a small percentage of Norplant users of severe pain or scarring from having it removed. But the apparent reason was inadequate training of physicians in the (usually quick and painless) removal procedure--an easily remedied problem--and not any inherent defect in the product.

It is sexist to seek to thrust contraception only upon women.

Sexism has nothing to do with it. First, almost all welfare checks are written to women--not to men, who don't get pregnant. Second, the only forms of contraception now available for men are condoms and vasectomies. It would hardly make sense to hand out $1,000 payments to men for taking home a bunch of condoms, or to try to police their use. And a vasectomy--unlike a Norplant implant-- cannot always be reversed.

Giving teen-agers contraceptives encourages promiscuity, and bribing them to use Norplant will encourage it even more.

The weight of the evidence suggests that teen-agers' decisions whether or not to engage in sexual activity don't have much to do with whether the government gives them contraceptives. Many have unprotected sex, and almost all can get contraceptives if they want them. As I have suggested, one possible restriction (although not one I would favor) on any Norplant incentive program would be to limit eligibility to teen-agers who have already been pregnant or, at least, sexually active. Norplant counselors could also stress the benefits of abstinence, while presenting the contraceptive as a backup safeguard.

Teen-agers should learn about sex and contraception from their parents, not the government.

A parental-consent requirement would answer this objection. I would not advocate such a requirement, however, because of the overwhelming evidence that many parents have little or no constructive communication with their children about such matters. I hope that my own two daughters (now 12 and nine years old) would consult with me and my wife before getting Norplant or becoming sexually active. But if they end up deciding to go their own ways, I'd rather that they have unrestricted access to Norplant than that they risk pregnancy.

Would a Norplant program be thwarted by the fact that many poor teen-agers actually want to get pregnant and have a child? I don't think so. First, there are about 3 million unwanted pregnancies in the United States every year, half of which end in abortion. Many of these involve teen-agers and women who are (or will be) on welfare. Norplant could stop almost all these. Second, the allure of pregnancy for many other poor teen-agers may be so slight, or so fleeting, or so fraught with ambivalence, that a $1,000 Norplant incentive would have plenty of takers.

And even if such a program only delayed pregnancies a few years, that would be a very good thing. Most 15-year-olds would be better mothers, and have a better chance of making something of their own lives, if they waited five or seven years before having babies.

Norplant is no panacea for poverty; nothing is. The question is whether a Norplant incentive program might do some good. There's only one way to find out: Give it a try. If it fails, the cost--in terms of numbers of teen-agers and women taking the $1,000 offer--will be tiny. And it just might help.